FWCOC Summer Enrichment Program

* Child's Full Name

* Street Address

* City

* State

* Zip Code

* Home Phone

* Parent's Email

* 2021/2022 Grade Level

* Child's Birth Date

* Age

* Select One:

Male Female

Parents & Alternate Emergency Phone Numbers for Day & Night

Father's Name

Father's Phone Number

Mother's Name

Mother's Phone Number

Alternate Name

Alternate's Phone Number

Medical Release and Information

I give permission for the Director and/or Staff to take my child (name listed above) to the hospital for medical treatment, in case of an accident or illness, and to receive medication(s) prescribed by the attending physician(s).

* Medical Release Affirmation

* Doctor's Name

* Doctor's Phone Number

* Medical Insurance Company

* Insurance Group No.

* Insurance Company Phone Number

Please answer all the following questions:

* Does this child have any allergies, drugs or otherwise? If yes, please list:

* Does this child have any chronic illness? If yes, please list:

* Has this child had surgery within the last year? If yes, please list:

* Is this child taking any medication(s)? If yes, please list:

* Has this child had a Tetanus shot within the last six months?

* Please check any of the following this child has had:

Measles Chicken Pox Mumps Polio Diphtheria Whooping Cough None of the above

I give permission for my child (name listed above) to participate in all activities, including water activities, during the Fifth Ward Church of Christ 2022 Summer Enrichment Program.

* Parent/Guardian Name - person authorizing the registration

* Permisson affirmation

FWCOC Summer Enrichment Program

2022 Summer Enrichment Child Registration Form

2022 Summer Enrichment Volunteer Form